Clinical expertise in the era of evidence-based medicine and patient choice
Clinical expertise in the era of evidence-based medicine and patient choice
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循证医学和患者选择时代的临床专业知识
DOI：
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发表时间：
2002
期刊：
影响因子：
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通讯作者：
G. Guyatt
中科院分区：
文献类型：
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作者：
Haynes Rb;P. Devereaux;G. Guyatt
您正在护理一名68岁的男性，他患有高血压（间歇性控制），伴有远端胃肠道出血和非瓣膜性房颤（NVAF）3个月，左心房增大（因此不太可能进行心脏复律）。患者无卒中或短暂性脑缺血发作病史。他的父亲几年前经历了一次衰弱的中风，当他得知他的房颤使他中风的风险更高时，他明显感到痛苦。
循证医学的概念正在演变为早期模型的局限性得到解决。在这篇社论中，我们提出了一个基于患者情况，患者偏好和行动以及最佳研究证据的循证临床决策的新模型，临床专业知识在整合这些组件方面发挥着核心作用。
传统上，临床医生根据他们在诊断和处方或管理治疗方面的技能被认为具有临床敏锐性。生物医学研究的重大投资的出现，导致新的和更好的测试和治疗，刺激了医学文献和循证医学的批判性评价的发展，1和应用目前最好的证据，从医疗保健研究现在是一个预期的辅助临床敏锐度。
最初，循证医学主要集中在确定与临床问题或决策相关的最佳研究证据，并应用这些证据来解决问题。这种早期的提法淡化了临床决策的传统决定因素，包括生理学原理和个人临床经验。循证决策的后续版本强调，仅凭研究证据并不足以指导行动。相反，临床医生必须运用他们的专业知识来评估患者的问题，并且在提出管理建议之前还必须结合研究证据和患者的偏好或价值观（图1）。
图1
循证临床决策关键要素的早期模型
图...
You are caring for a 68 year old man who has hypertension (intermittently controlled) with a remote gastrointestinal bleed and non-valvular atrial fibrillation (NVAF) for 3 months, and an enlarged left atrium (so cardioversion is unlikely). The patient has no history of stroke or transient ischaemic attack. His father experienced a debilitating stroke several years ago and when he learns that his atrial fibrillation places him at higher risk for a stroke, he is visibly distressed.
The concepts of evidence-based medicine are evolving as limitations of early models are addressed. In this editorial, we present a new model for evidence-based clinical decision making based on patients' circumstances, patients' preferences and actions, and best research evidence, with a central role for clinical expertise to integrate these components.
Traditionally, clinicians have been credited with clinical acumen according to their skills in making a diagnosis and prescribing or administering a treatment. The advent of major investments in biomedical research, leading to new and better tests and treatments, has spurred the development of critical appraisal of the medical literature and evidence-based medicine,1 and application of current best evidence from healthcare research is now an expected adjunct to clinical acumen.
Initially, evidence-based medicine focused mainly on determining the best research evidence relevant to a clinical problem or decision and applying that evidence to resolve the issue. This early formulation de-emphasised traditional determinants of clinical decisions, including physiological rationale and individual clinical experience. Subsequent versions of evidence-based decision making have emphasised that research evidence alone is not an adequate guide to action. Rather, clinicians must apply their expertise to assess the patient's problem and must also incorporate the research evidence and the patient's preferences or values before making a management recommendation (figure 1).2
Figure 1
Early model of the key elements for evidence-based clinical decisions
Figure …
影响因子：
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作者：
通讯作者：
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影响因子：
5.9
作者：
Beyth, RJ;Quinn, LM;Landefeld, CS
通讯作者：
Landefeld, CS